Making It to Sustainability: Evaluating Billing Strategies for Collaborative Care
Abstract
The collaborative care model (CoCM) is an effective strategy to manage common mental disorders in primary care. Despite the growing adoption of newer CoCM billing codes to support these programs, few studies have investigated the use of these codes. This column evaluated the implementation of CoCM billing codes by comparing clinics using different billing strategies and assessed the impact of CoCM code implementation on revenue and on clinical and process-of-care outcomes. Qualitative data were obtained to understand provider perspectives. The results indicate that CoCM billing code implementation is operationally feasible, does not adversely affect the delivery of patient care or revenue, and is acceptable to providers.
HIGHLIGHTS
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Data on the type and amount of activities performed within a collaborative care model can help organizations choose the optimal billing modality.
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Monitoring key quality metrics with real-time data, including the time behavioral health care managers spent on activities, helps to discern any variation in provision of services and ensures model fidelity.
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Developing a consistent and standardized approach to tracking minutes of billable service is key, especially when implementing new time-based billing codes.
The collaborative care model (CoCM) is regarded as one of the most established evidence-based models of integrated behavioral health care since the IMPACT trial in 2002 showed its effectiveness in a large randomized controlled trial (1). Yet it was not until 2017 that the Centers for Medicare and Medicaid Services (CMS) introduced billing codes designed to support CoCM (2). These new codes are billed monthly for the full range of services provided in this care model and account for time spent by a behavioral health care manager (BHCM) on both direct and indirect patient services (such as care coordination, care team communication, and psychiatric consultation). CoCM billing offers an opportunity for reimbursement for services that are unbillable via psychotherapy billing codes and could help make the provision of CoCM services more financially sustainable. A few studies on the use of the CoCM billing codes (3–5) have cited significant barriers that primary care clinics face in implementing this billing model, including the challenges of obtaining and documenting patient consent, difficulties with billing workflow changes, and the need for engagement of multiple stakeholders and procedures (such as clinicians, leadership, and specialists in billing, coding, and compliance). Many CoCM practices have therefore chosen to continue to bill only for the direct patient services provided by the BHCM via traditional psychotherapy codes.
However, the exclusive use of psychotherapy billing codes results in critical pieces of CoCM services being provided without reimbursement and limits the workforce that can perform the role of the BHCM to independently licensed providers. Additionally, some payers impose restrictions for behavioral health claims; however, with CoCM billing codes the primary care provider (PCP) submits the claims for these services under the medical benefit (not specialty behavioral health) category, which may allow for more patients to receive care. Thus, the use of CoCM billing codes could encourage more practices to implement CoCM with full fidelity and provide revenue to sustain the model at more primary care sites, while broadening the available workforce and expanding access to care.
In this column, we report on one health care system’s experience with implementing CoCM billing codes and assess the impacts of the implementation on health care delivery and financial revenue by using both quantitative and qualitative data. The primary aim was to compare clinics that adopted CoCM billing with clinics that continued billing only with traditional psychotherapy codes and evaluate how this difference in billing may have affected the minutes of patient care delivered and the estimated revenue associated with these services. The secondary aim was to look more closely at categorization of the minutes associated with CoCM billing and how the BHCM’s time was being used. Furthermore, interviews with PCPs and BHCMs provided perspectives on the CoCM billing code implementation and its effect on clinic workflow and the delivery of patient care.
Intervention
The University of Washington (UW) Medicine Primary Care network is part of a large urban academic health care system that serves a diverse patient population. The primary care clinics included in this study had a similar payer mix, except for the pediatric clinic, which had a high percentage (63.3%) of Medicaid patients (see the online supplement to this column for background information on clinics). This high percentage was likely due to the location of this clinic, serving a large catchment area, including rural and underserved areas.
UW Medicine has an established collaborative care program, and all participating sites operate under the same clinical model. Historically, the BHCM role was staffed by licensed social workers who used psychotherapy billing. In 2019, the use of CoCM billing codes started at two clinics (one being a pediatric clinic) that implemented CoCM billing in addition to psychotherapy billing (“hybrid billing”). After a 6-month pilot phase, four additional clinics instituted CoCM billing exclusively (“CoCM-only billing”), and this group was compared with four clinics that continued with psychotherapy billing only.
This retrospective, observational study used data from the electronic health record (EHR) and billing data from two 6-month periods, before CoCM billing implementation (July 2018–December 2018) and after implementation (September 2019–February 2020). The study evaluated three primary outcome measures: average number of minutes of clinical service per month provided by the BHCM, average number of visits per month with the BHCM (both used to estimate revenue), and average number of unique patients per month served by the BHCM. The numbers of visits and unique patients were obtained from EHR data, and visits included billable visits as well as nonbillable visit types (e.g., telephone calls) (see the online supplement ). For the clinics using psychotherapy billing only, the number of minutes of clinical service was estimated with the CPT codes (6) billed (see the online supplement ). For CoCM billing, the number of minutes was obtained from the EHR, in which the BHCM directly recorded the actual time spent.
The estimated revenue from the billable services was calculated in two ways. For psychotherapy billing, the reimbursement rates published in the CMS 2021 Physician Fee Schedule (7) were applied to the psychotherapy CPT codes submitted (see the online supplement ). For the clinics using CoCM billing, the actual number of CoCM minutes recorded in the EHR were used to determine the appropriate CoCM billing code, and the reimbursement rates from the CMS 2021 fee schedule were then applied. Because of variable BHCM staffing during some months, the mean numbers of BHCM visits and unique patients seen at each clinic were adjusted on the basis of the mean clinical full-time equivalent (cFTE) of the BHCM. Monthly averages were calculated across each of the two 6-month study periods. Average monthly values for the variables were then calculated, and the statistical significance of differences between the psychotherapy billing clinics and the CoCM billing clinics was evaluated with a Mann-Whitney U test. Given the limited number of hybrid clinics, statistically significant differences were not evaluated for these clinics.
For clinics that implemented CoCM billing, two secondary measures were included to evaluate processes of care. First, a detailed breakdown of the types of clinical activities attributed to CoCM billing was conducted, including time spent with patients or families, care coordination, chart review, or case review with providers or psychiatric consultants (8). Second, we estimated the amount of service minutes that went unbilled in any given month because they were either above or below the billing threshold.
Qualitative, semistructured interviews were conducted (9) with providers from each clinic to obtain their impressions of the CoCM billing implementation and how it affected their work and clinic workflow. This protocol was reviewed and granted exemption by the University of Washington Human Subjects Division (STUDY00010726).
Results and Interpretation
The focus of this study was on data from our institution’s initial CoCM billing implementation, which was used to better inform the implementation process and assess any early impacts on patient care or financial reimbursement. Our investigation is the first study we are aware of that compares clinics using different billing strategies.
Overall, when comparing the two clinic groups (psychotherapy billing vs. CoCM-only billing), we observed no statistically significant changes (at α=0.05) from pre- to postimplementation in the primary outcomes: number of BHCM visits, unique patients served, average estimated minutes billed per month and potential estimated revenue (see the online supplement ). The CoCM-only billing clinics exhibited some pre-post variability, but when averaged, no significant differences were observed among them, indicating that the implementation of CoCM billing codes was not detrimental to clinical services or revenue generated.
When further examining variability among the CoCM-only billing clinics, we noted that one major factor affecting the data was variable staffing of BHCMs and differences in cFTEs. Several BHCMs left during the preimplementation phase, and the newly hired BHCMs (placed in the CoCM-only clinics) started in the postimplementation phase. Although we observed no significant differences in our primary outcomes between these two periods, we suspect that these staffing changes had a negative impact on the number of BHCM visits, number of unique patients served, and, ultimately, CoCM revenue for the CoCM-only billing clinics. The variation in staffing levels could have been a confounding factor affecting our ability to interpret the impact of the CoCM billing implementation and underscores how staffing turnover can have considerable impacts on service delivery and ultimately revenue.
In addition to variation in staffing, we also observed a variation in the amount of the time spent by the BHCM on various clinical activities. For example, certain clinicians spent more time than others on case or chart reviews or care coordination (see the online supplement ). This difference could have been due to differences in individualized workflows or in how familiar and experienced the BHCM was at tracking CoCM billing time. The variation in the amount of time spent on clinical activities highlights the importance of training BHCMs to have a consistent approach, including how to accurately document and bill for their time. Having regular oversight of BHCM activities and the use of real-time data or quality metrics would help identify areas where a BHCM may need additional support and training.
Examining the hybrid billing clinics, we found that the adult hybrid clinic used CoCM billing about 12.8% of the time (N=2,603 of 20,328 total billed minutes), with CoCM activities split almost evenly between direct services and case reviews, and for direct services the psychotherapy codes were used most of the time (87.6%, N=17,725 of 20,238). The pediatric hybrid clinic used CoCM billing 44.1% of the time (N=9,110 of 20,660 total billed minutes), with CoCM billing approaching rates of psychotherapy billing codes (55.7%, N=11,500 of 20,660) (see the online supplement ). The pediatric hybrid clinic also spent a substantial amount of time on care coordination (14.1%, N=2,913 of 20,660) and chart review (6.8%, N=1,410 of 20,660), which represent clinical activities not typically billable under psychotherapy billing.
The addition of CoCM billing likely contributed to the 142% increase in minutes billed and the resulting 133% increase in estimated revenue during the post-CoCM implementation period in the pediatric hybrid clinic (see the online supplement ). Moreover, 20.9% (N=84 of 402) of this clinic’s monthly patient CoCM minute totals fell under the minimum threshold to bill (using the original minimal threshold of 36 minutes of CoCM services per patient in the first month of service or 31 minutes in a later month) but would now be eligible for billing using the new G2214 code released by CMS in 2021 (which allows for billing between 16 and 30 minutes of CoCM services per patient in any service month). This finding contrasted with those for the adult hybrid clinic, which had 14.9% (N=20 of 134) of the monthly patient CoCM minute totals fall in this category and a 4.4% (N=26 of 594) average for CoCM-only billing clinics.
Of note, the two hybrid clinics had the lowest proportion of instances where minutes were over the maximum threshold, with totals of monthly patient CoCM minutes exceeding the maximum allowed about 1% of the time (0.7%, N=1 of 144, for the adult hybrid clinic and 1.0%, N=4 of 402, for the pediatric hybrid clinic), whereas the CoCM-only billing clinics had a mean of 6.9% (N=41 of 594) (see the online supplement ). CoCM billing thresholds are important to consider when choosing a billing strategy, because a minimum and a maximum number of minutes can be billed per calendar month. Many existing integrated care practices use a hybrid clinical model, either deploying CoCM alongside licensed clinicians in the practice delivering psychotherapy or combining CoCM with other clinical models. These different CoCM approaches underscore the importance of learning how billing could affect services and financial sustainability; therefore, having data on how much time BHCMs spend, and on what type of activities, can help an organization choose which billing modality would be optimal for their practice.
The qualitative results showed that clinicians had generally positive opinions about CoCM billing. Some clinicians shared concerns about the operational efficiency and administrative work associated with the billing process, and some raised concerns about transparency and patient equity. However, most felt that the process was not overly burdensome and added value for their patients and clinical practice. Specifically, clinicians commented on how CoCM billing expands coverage for mental health services and improves access for patients (particularly for those with Medicaid or Medicare) and that CoCM billing allows for more flexibility for patients to be seen in person or remotely (see the online supplement for full interview findings, including example quotations).
Limitations of this study included the small sample size and short observation periods, which likely amplified the variations caused by staffing issues and the lack of familiarity with CoCM billing. Including more clinics or having a longer evaluation period might provide more reliable data on differences among clinics. Also, the estimated potential revenue was based on CMS rates but did not account for actual reimbursement rates and percentage of services reimbursed or denied, which can greatly affect overall revenue.
Conclusions
These preliminary findings suggest that adopting CoCM billing codes does not adversely affect the number of services delivered or financial revenue. The qualitative data indicate that CoCM billing implementation is feasible, with most clinicians noting improved value for their practice with minimal added burden. Although this study validates the notion that CoCM billing codes can produce adequate reimbursement without excessive burden, we speculate that CoCM billing potentially provides a financial benefit that was not verified by our results, primarily because of the number of confounding and limiting factors. Therefore, additional studies will need to assess the longer-term impact of CoCM billing.
In summary, CoCM billing requires resources to implement and sustain but has the potential to enhance clinical services and benefit the financial stability of clinics. The availability of CoCM billing codes could encourage more practices to implement CoCM and to do so with full fidelity, while also increasing access to care and expanding the workforce.
Footnote
Dr. Bowen passed away on August 20, 2022.
Supplementary Material
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References
1.
Unützer J, Katon W, Callahan CM, et al: Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288:2836–2845
2.
Press MJ, Howe R, Schoenbaum M, et al: Medicare payment for behavioral health integration. N Engl J Med 2017; 376:405–407
3.
Carlo AD, Unützer J, Ratzliff ADH, et al: Financing for collaborative care—a narrative review. Curr Treat Options Psychiatry 2018; 5:334–344
4.
Carlo AD, Corage Baden A, McCarty RL, et al: Early health system experiences with collaborative care (CoCM) billing codes: a qualitative study of leadership and support staff. J Gen Intern Med 2019; 34:2150–2158
5.
Carlo AD, Drake L, Ratzliff ADH, et al: Sustaining the collaborative care model (CoCM): billing newly available CoCM CPT codes in an academic primary care system. Psychiatr Serv. 2020; 71:972–974
6.
CPT 2021, Professional Edition. Chicago, American Medical Association Press, 2020
7.
Physician Fee Schedule. Baltimore, Centers for Medicare and Medicaid Services, n.d. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched. Accessed Nov 28, 2021
8.
Behavioral Health Integration Services. Baltimore, Centers for Medicare and Medicaid Services, 2022. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf
9.
Moser A, Korstjens I: Series: practical guidance to qualitative research. Part 1: introduction. Eur J Gen Pract 2017; 23:271–273
Information & Authors
Information
Published In
History
Received: 25 November 2022
Revision received: 19 February 2023
Accepted: 22 February 2023
Published online: 20 March 2023
Published in print: November 01, 2023
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Competing Interests
Dr. Chang received honoraria for lectures at DC Health. Dr. Ratzliff has received book royalties from Wiley. The other authors report no financial relationships with commercial interests.
Funding Information
This project was funded by an anonymous donor gift.
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